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241. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … The communicator can also note that most adverse events have multiple causes that include a mixture of

242. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=94
     January 01, 2024 - The association of nursing home characteristics and quality with adverse events after a hospitalization … This study looked at trends in patient characteristics and in-hospital adverse events (AEs) for primary … Time trends in patient characteristics and in-hospital adverse events for primary total knee arthroplasty … Keywords: Surgery, Orthopedics, Adverse Events, Risk Bierman AS , Wang J , O'Malley PG … Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events

243. Data Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/data/resources/index.html
     November 25, 2021 - HCUP Statistical Briefs: Adverse Events These HCUP Statistical Briefs provide statistics about … adverse events and patient safety-related events in U.S. hospitals. … Topics include infections (CDI and MRSA), adverse drug events (ADEs), and potentially avoidable injuries

244. Cusp Patient Family Engagement Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
     September 13, 2013 - event Slide 21 SAY: Adverse events occur when a patient is harmed as a result of receiving medical … Medical providers are committed to caring for their patients; however, adverse events can happen. … Slide 25 SAY: Adverse events are often system failures. … Hospitals today recognize that health care workers are the second victims of adverse events and often … events.

245. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202104.html
     October 01, 2021 - CommonSpirit Health clinicians have communicated promptly and candidly with patients about an adverse … event or potential adverse event, and officials estimate 85 patients were spared the additional harm … “It’s all about how to communicate an adverse event or a potential adverse event promptly and candidly … However, “We’re never looking at events or other hard data to substantiate our position. … “CANDOR is absolutely the right approach for all involved in an adverse event,” Pelletreau said.

246. Translating Patient Safety Research into Clinical Practice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Relationship between medication errors and adverse drug events. … Systems analysis of adverse drug events. JAMA. 1995 (274):35–43. 9. … Incidence of adverse events and negligence in hospitalized patients. … Top-priority actions for preventing adverse drug events in hospitals. … The clinical pharmacist’s role in preventing adverse drug events.

247. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
     January 01, 2024 - They decided to use the phrase “negative effects” instead of “adverse events.” … A pre- specified list of adverse events and an evidence-based clinical case definition for each AE was … For the self-reported adverse events, two physicians reviewed patients’ responses from the survey, in … which they provided open-ended responses that described possible adverse events. … Adverse drug events were the highest type of adverse event reported by patients and recorded in the

248. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     November 06, 2017 - Events SAY: There are four sets of On-Time reports to help prevent four adverse events: pressure …  Commitment to work with a Facilitator to learn how to use the reports to prevent adverse events … For example, for some adverse events, the dietitian is an important member of the team because declining … The reports:  Focus on preventing adverse events.  Are proactive rather than reactive. …  Improve root cause analyses when adverse events occur.

249. AHRQ HAC 2015 Interim Data Graphic V03C (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-infographic-2015.pdf
     January 01, 2015 - 21%21% LIVES SAVEDLIVES SAVED 125,000125,000 IN SAVINGSIN SAVINGS $28 BILLION $28 BILLION FEWER ADVERSE … EVENTS FEWER ADVERSE EVENTS 3 MILLION3 MILLION From 2010–2015, more than 3 million hospital-acquired

250. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=247
     January 01, 2024 - Keywords: Adverse Drug Events (ADE), Adverse Events, Health Information Technology (HIT), Healthcare … Keywords: Adverse Events, Communication, Medical Liability Carayon P , Wooldridge A , Hose … Data mining for adverse drug events with a propensity score-matched tree-based scan statistic. … Keywords: Adverse Drug Events (ADE), Adverse Events, Patient Safety, Medication, Medication: Safety, … Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information

251. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=349
     January 01, 2024 - Take-homes from these exercises included the fact that the response to adverse events can be complex, … Improving communication and resolution following adverse events using a patient-created simulation exercise … Keywords: Adverse Events, Communication, Labor and Delivery, Outcomes Ducoffe AR , York A , … This article focuses on recommendations from the Adverse Drug Events (ADE) Action Plan to help guide … Keywords: Prevention, Opioids, Patient Safety, Ambulatory Care and Surgery, Adverse Drug Events (ADE

252. User Guide: COVID-19 Vaccination Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/vaccination-tracking-tool-userguide.pdf
     May 01, 2021 - This is important because if you are seeing increased adverse events related to a specific vaccine … This is important because if you are seeing increased adverse events related to a specific vaccine … Events by Manufacturer. … Figure 16 – Example Adverse Events pie chart 17 The STAFF_SUMMARY Tab contains an additional … Events following COVID-19 Vaccine(s).

253. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
     April 01, 2018 - The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada … Detecting adverse events using information technology. … Adverse Events in Hospitals: Methods for Identifying Events. … Adverse events among children in Canadian hospitals: The Canadian Paediatric Adverse Events Study. … Adverse events and preventable adverse events in children.

254. Is There an Association Between Patient Safety Indicators and Hospital Teaching Status? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
     April 28, 2008 - Conclusion: Further research is needed on the relationship of residency programs to adverse events. … For example, older and sicker patients are often at higher risk for incurring adverse events.4, 7, 8 … Postoperative adverse events in teaching and nonteaching hospitals. … Patient risk factors for adverse drug events in hospitalized patients. … Hospital ownership and preventable adverse events. J Gen Intern Med 2000; 15: 211-219. 24.

255. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=124
     January 01, 2024 - Transforming the medication regimen review process using telemedicine to prevent adverse events. … Transforming the medication regimen review process using telemedicine to prevent adverse events. … Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, … Drug Events (ADE), Adverse Events, Risk, Patient Safety, Blood Pressure Kemme S , Stahl M , … Keywords: Cancer: Lung Cancer, Cancer, Adverse Drug Events (ADE), Adverse Events, Medication

256. Improving Antibiotic Use is a Patient Safety Issue
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
     November 01, 2019 - Events Improving Antibiotic Use – Patient Safety Issue AHRQ Safety Program for Improving Antibiotic … Use – Acute Care 5 5 Antibiotic-Associated Adverse Events In a cohort of ~1,500 hospitalized patients … developed antibiotic-associated adverse events after hospital discharge Most adverse events had some … Approximately 20% of hospitalized patients develop antibiotic-associated adverse events. … Association of Adverse Events with Antibiotic Use in Hospitalized Patients.

257. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/index.html
     August 01, 2017 - System in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Events in Labor and Delivery Patient Safety Culture and Medical Liability—Recommendations for Measurement … Drug Events During Transfer of Care from Hospital to Home In October 2009, AHRQ launched … Hickson Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor … Bolkan Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital

258. Detailed Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/findings.html
     August 01, 2022 - The grantee reported the following findings about the first 125 adverse events resolved through the communication … events). … Communication-sensitive adverse events (CSAEs). 9 the term “CSAE” was coined by the UW project and defined … The grantee reported findings on four composite scores that measure perinatal adverse events: the Adverse … The thinking was that the DRPs would be utilized by the hospitals to disclose adverse events, and the

259. Early Mobility in the Intensive Care Unit: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-fac-guide.html
     February 01, 2017 - Slide 11: Safety Say: There were no serious adverse events. … Patients were started on a careful trial of activity, and close watch was kept for adverse events. … Slide 14: Adverse Events Say: Nine patients had a total of 14 adverse events. … This study had no documented adverse events in either arm. … The adverse events discussed in these articles range from agitation to transient physiological events

260. Final Progress Report: Mentored Implementation of I-PASS for Better Handoffs and Safer Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/23291-Landrigan-report.pdf
     September 29, 2018 - Handoff-related adverse events decreased by 42%. All changes were p < 0.05. … Handoff-related Adverse Events In total, 1698 reports of handoff-related adverse events were collected … Rate of handoff-related adverse events. … Reported as the number of events per person-year for both major and minor handoff-related adverse events … Does housestaff discontinuity of care increase the risk for preventable adverse events?